ESC 2023 Guidelines for Management of Infective Endocarditis
The 2023 European Society of Cardiology (ESC) guidelines for infective endocarditis (IE) strongly recommend managing complicated IE cases at specialized centers with an Endocarditis Team and immediate access to cardiac surgery, while emphasizing a multidisciplinary approach for optimal patient outcomes. 1
Key Updates in the 2023 ESC Guidelines
Endocarditis Team and Referral System
- Complicated IE cases (with heart failure, abscess, embolic/neurological complications, or congenital heart disease) must be referred early to a reference center with immediate surgical capabilities 2
- Non-complicated IE can be managed at non-reference centers with regular communication with the reference center and the multidisciplinary Endocarditis Team 2
- The Endocarditis Team should include:
- Cardiac surgeons
- Cardiologists
- Infectious disease specialists
- Microbiologists
- Specialists in valve diseases, imaging, and neurology 2
Antibiotic Prophylaxis
- Less restrictive recommendations now favor individualized prophylaxis for intermediate-risk patients (bicuspid aortic valve, degenerative/rheumatic valve disease) undergoing dental procedures 3
- Clear recommendation for prophylaxis in high-risk patients (prosthetic valves) 3
Diagnostic Approach
- Enhanced multimodality imaging for improved diagnosis, particularly for prosthetic valve endocarditis 1
- PET-CT has been incorporated into diagnostic criteria for prosthetic valve endocarditis 4
Antibiotic Treatment
Empirical Treatment
For community-acquired native valves or late prosthetic valves:
- Ampicillin/amoxicillin (200 mg/kg/day IV in 4-6 doses)
- Gentamicin (3 mg/kg/day IV or IM in 1 dose)
- Consider adding vancomycin for penicillin-allergic patients 2
For early PVE (<12 months post-surgery) or nosocomial IE:
- Vancomycin (30 mg/kg/day IV in 2 doses)
- Gentamicin (3 mg/kg/day IV or IM in 1 dose)
- Rifampin (900-1200 mg IV or orally in 2-3 divided doses) for PVE, started 3-5 days after vancomycin and gentamicin 2
Pathogen-Specific Treatment
- HACEK organisms: Ceftriaxone 2 g/day for 4 weeks (NVE) or 6 weeks (PVE) 2
- Enterococcus spp.: Amoxicillin/ampicillin (200 mg/kg/day IV in 4-6 doses) plus gentamicin (3 mg/kg/day) for 6 weeks (8 weeks for PVE) 2
Treatment Duration
- Native valve IE: Minimum 4 weeks
- Prosthetic valve IE: Minimum 6 weeks 5
Outpatient Antibiotic Therapy
- New recommendation: Stable patients with left-sided IE caused by streptococci, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci can transition to ambulatory (oral or parenteral) antibiotic therapy after at least 10 days of appropriate IV therapy 3
- OPAT should be considered only after the critical phase (first 2 weeks) and for medically stable patients without complications 2
Surgical Management
Indications for surgery:
- Heart failure due to severe valve regurgitation/obstruction
- Uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation)
- Prevention of embolic events (persistent vegetations >10mm after ≥1 embolic episodes)
- Infection by fungi or multiresistant organisms 5
Timing of surgery is classified as:
- Emergency (within 24 hours)
- Urgent (within 3-5 days)
- Non-urgent (within the same hospital stay) 4
Post-stroke patients: Ischemic stroke should not delay necessary surgery; hemorrhagic stroke may require delay up to 4 weeks depending on clinical condition 4
Follow-up Care
- Clinical evaluation at 1,3,6, and 12 months after hospital discharge 2
- Echocardiographic follow-up during treatment and at completion 5
- Blood cultures if recurrent fever occurs 5
- Dental follow-up and emphasis on prophylaxis for future procedures 5
Common Pitfalls to Avoid
- Inadequate empiric antibiotic coverage
- Failure to consult specialists in complex cases
- Delayed surgical evaluation when indicated
- Premature narrowing of antibiotic spectrum
- Inadequate duration of therapy 5
The 2023 ESC guidelines emphasize a patient-centered approach with shared decision-making by a multidisciplinary team, structured referral systems between heart valve centers and referral centers, and timely surgical intervention for complicated cases to improve outcomes in IE patients.